28 June 2010

I don't know what is going on with ACEP lately, but it's disheartening. Their abdication of responsibility and engagement during the health care reform debate was depressing. Then there was a rigged poll designed to elicit a predetermined result. Now I see a bizarre op-ed piece in USA Today authored by ACEP President Angela Gardener:

Opposing view on drug addiction: Don't make us 'pain police'The patient-physician relationship is sacrosanct, demanding candor and trust. In the emergency department, trust is built in nanoseconds because patients and doctors do not have prior relationships. Knowing that any pain prescription will be entered into a large, public database might prevent patients from being truthful, or in the worst case, from seeking needed care. ... As an emergency physician, I can assure you that the drug abusers who use the emergency room simply to get a prescription drug fix represent a micropopulation of the 120 million patients who seek emergency care every year in the USA. ... Put bluntly, if legislators have money to spend, they should spend it where it will do the most good for our patients, and that is not on drug databases.

I really don't know what to say, other than to wonder whether Dr Gardner and I practice in the same United States in which abuse of prescription drugs is growing exponentially and in which "drug-seeking" patients are a part of each and every shift worked in the ER, where deaths due to overdoses of prescription medications are on the rise, and where diversion of narcotics is a serious and growing problem.

Dr Gardner is correct when she writes that drug-seekers are a "micropopulation" of ER patients. But that is a meaningless measure of the problem. Acute myocardial infarctions are also a "micropopulation," as are hip fractures, asthmatics, and most every other complaint you choose to split out from the nation's ER census. (Indeed, in many ERs, low back pain is the #1 discharge diagnosis.) To minimize the problem, to dismiss it as a "micropopulation" is to willfully turn a blind eye to the disease and its human cost.

And make no mistake: addiction to prescription medication ruins lives, and kills people. I vividly remember the tragic case of Debra. A combat veteran, she had been thrown out of the Navy after acquiring a chronic painful condition which had been poorly managed, leading to dependence on opiates and sedatives. Dependence turned into addiction and I saw her numerous times over a two year period. In some cases she was looking for refills, in some she complained of pain exacerbations, and in some she was unresponsive after overdoses. It was a real challenge figuring out who was supplying her with meds (she had dozens of doctors) and in the end she was reduced to taking veterinary sedatives ordered from Mexico. I spent a lot of time trying to get her into treatment, without success. One day I saw her name on the list of patients to be seen. I sighed and went into the room and was shocked: it was the same patient, but a very different person. She had a tracheostomy tube and was on a ventilator; there was a tube in her stomach for nutrition, and one in her bladder for elimination. Her mother, with a sad look, sat by her bedside. (No family members had ever accompanied her to the ER before.) She explained that a couple of months prior, Debra had overdosed again, but this time she had stopped breathing and had suffered an anoxic brain injury, leaving her in a permanent vegetative state.

We ER docs are on the front lines of this as so many other social challenges. We need all the tools that are available to combat these problems. I agree that it would be onerous to be required to check a database every time I wrote for a controlled substance. That should be changed. But if it is possible to compile the data, give it to us and let us use it as needed when we have concerns.

Because trust needs to be established between the doctor and patient, and in some cases the maxim, "trust, but verify" is appropriate. If I have concerns that a patient is not being honest with me, if I have concerns that their story doesn't sound quite right, information is an important tool to open up the discussion and maybe prevent further tragedies, or at least reduce the role of the ER physician as an unwitting enabler of ongoing drug abuse.

It's depressing to see the leaders of our specialty opposing such common-sense measures to improve patient safety and enhance our ability to deliver appropriate care.

15 comments:

Really?! Because the government does such a good job with their databases. I can hardly wait.

Like the time TX denied me a driver's license because MS had a gal with the same exact name & DOB as me flagged. Now with a DL not such a huge deal that it took 2 WEEKS to straighten out, but if I'm pain. I think 14 days might bother me just a little bit more. I can only imagine the fun of being in a ER and proving I'm not the person in the database.

And what about when patient J comes in? What if you do check them and their name pops up as a drug seeker, but you are convinced they really do need some drugs? And then they OD? Have fun explaining yourself in a criminal court, because I can guarantee you that's where this would end up. The rules & regs make no exceptions for common sense and doing the right thing.

You should write a response to that esteemed journal. Somebody should, and mine would just come out...ARGHHHHHH.

I don't belong to ACEP and I feel guilty every once and awhile about that. (I work as an IC and don't get CME money -- I think the dues are pretty steep if you don't have someone else paying them). This post will help decrease the guilty feelings.

Missy: you don't work in an ER. You don't get it. Sorry you hate the government, but I think there are better blogs to express that. If you are not a drug seeker and go to your local ER, you would have very little to worry about.

For the past few years, Colorado has had a database program, the Prescription Drug Monitoring Program and it has been a GODSEND. It has actually enhanced care in multiple ways-- not only can you verify someone you are getting the seeker vibe from is NOT actually a seeker, but by identifying those who are, you can direct them to the care they need (not necessarily want, but NEED.) If you don't think you need it, don't use it. I'll be moving to OR in a few weeks and wish there was a similar program in that state.

I agree with you that drug abuse and drug seeking behavior is much more prevalent than the press release would lead people to believe. I also agree that the narcotics databases are extremely useful.

But you need to realize that Angela Gardner speaks as a representative of ACEP. Every ACEP president and every ACEP board member has some aspect of ACEP policy with which they disagree, yet as a representative of the organization, it would put them in a bad position if they aired their policy disagreements publicly. Consider whether you would go to news agencies and air your personal disagreements with your hospital's policies. Not so easy.

I know Angela personally and she is a great physician, an extremely intelligent person, and a great representative for our college.

I don't agree with everything that ACEP puts out in the news, either, but I think that overall ACEP is doing a good job advocating for emergency medicine. If you don't like the views of the college, get involved at the council meetings and speak your mind. Maybe you can change some of those views.

Chronic pain patients I know think they are too. For those who are legitamate, the doc can tell that as well. And the doc can see that there aren't multiple docs prescribing meds, and that the patient is totally compliant. Works both ways. I believe it really helps the legitamate patient.

Interesting, as an aside, the issue of trust. I don't see why it is assumed that there is trust between a patient and a doctor that have never met before. I trust doctors I've grown to know. Two complete strangers in the ER - why should the doctor trust me? Lots of patients lie to them. They don't know me. And honestly, I don't trust them either. Trust is something I give to someone that has earned it. Of course, I don't distrust them either - we'll see. But to assume automatic trust - I just don't get that.

I agree that it can be tough at times to reconcile the EDs role in providing rapid relief of severe pain and the role of identifying individuals who are misusing narcotics. If you are committed to treating pain you have to be prepared to be fooled once in a while by a particularly crafty drug seeker. That being said, most of these folks are not exactly international intelligence operatives ('I always take a dram of morphine in my martini'), most are repeat offenders, with repeat stories, and implausible excuses.My dog ate my oxys!My GP lost his DEA number!I have ridiculous syndrome X!Usually the story falls apart if you just sit there and say mmmhmm, mhhmmm, mmmmhmmm, a few times...Many of these folks also have track marks (frequently carefully hidden) when you examine them.Pain relief is a great part of my job, and offering to help drug addicted patients to get some help with their addiction is also a great part of my job. Sometimes the 2 overlap, and sometimes I get fooled. When that happens I don't worry about it, I just tell the patient that I think they fooled me, and that I have a long memory...

No need to assume Missy Ann is not cognizant of the problem. I think her points are valid. Most of these global decisions are not made by those who should make them, after all. If they were, we would not still be chasing our tails about them now would we.

We use drug data bases in B.C. Canada and it only makes sense. It is safer and not only is it good for the patient and the MD - but also for the Pharmacist. The anectdotal case of Missy does not an argument make. Get rid of all data bases iin the world and the result would be rampant confusion.

My girlfriend lives with severe chronic pain. The level of suspicion she deals with in trying to get the medications she needs to not be incapacitated by pain is so great that she ends up being afraid to take the medication she gets, for fear of running out too soon and getting labeled a drug-seeker. If doctors can check a database to verify that she is not doctor-shopping, this can only improve the care that my girlfriend receives. The only problem I can see with a database is if it is used to arbitraily punish doctors who prescribe "too many" painkillers, without taking into account patients' needs

Missy Ann has a point about databases, but misses the mark if she thinks it's only government databases that get screwed up.

All databases are subject to the GIGO problem.

What I fear is that using the database rationally as one tool in a box will eventually result in it becoming the most powerful tool that can override all the others.

There will inevitably be a mistake made and a high profile addict will OD on a prescription written by a physician with access to such a database. The legal system's reaction will be to override all physicians' professional judgement.

It will eventually become illegal to prescribe pain medication to any person listed on the database even if they present with a limb missing because they were on a train that derailed.

I do sympathize with those suffering from debilitating chronic pain. And I have no patience with those who think pain is a character enhancing good thing. (Some of these people do work as doctors.)

when prescribing pain meds to the "frequent fliers" my er has a new policy of considering whether there are any objective findings or if the symptoms are all subjective.

we find this helps prevent the over prescribing for pts with chronic pain that would be better served getting pain management from one provider.

if the patient is in a database and you can document why you gave them narcs, no problem. if the patient states they fell down a flight of stairs but haven't a single bruise or scrape on them you might want to be a little skeptical. if this is the 4th refrigerator your pt has moved this month in spite of having chronic back pain you might want to use some judgment before writing the narcotic rx.

expediting an er discharge or improved press-ganey scores are not valid reasons for prescribing narcotics.

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Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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